DOI: 10.1111/jch.

14186

C O M M E N TA R Y

Chronic kidney disease: Definition, updated epidemiology,

staging, and mechanisms of increased cardiovascular risk

Scott Wilson BA1,2 | Pasquale Mone MD3,4 | Stanislovas S. Jankauskas PhD1,2 |

Jessica Gambardella PhD1,2,5 | Gaetano Santulli MD, PhD1,2,5
1
Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York,
NY, USA
2
Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM),
Albert Einstein College of Medicine, New York, NY, USA
3
University of Campania “Luigi Vanvitelli”, Naples, Italy
4
ASL Avellino, Avellino, Italy
5
Department of Advanced Biomedical Science, International Translational Research and Medical Education Consortium (ITME), “Federico II” University, Naples,
Italy

Correspondence: Prof. Gaetano Santulli, Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert
Einstein College of Medicine, New York, NY 10461, USA and Department of Advanced Biomedical Science, International Translational Research and Medical
Education Consortium (ITME) “Federico II” University, Naples 80131, Italy.
Email: gsantulli001@gmail.com

Funding information
The Santulli’s Laboratory is supported in part by the National Institutes of Health (NIH): National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK: R01-DK123259, R01-DK033823, R00-DK107895), National Heart, Lung, and Blood Institute (NHLBI: R01-HL146691, T32-HL144456), National
Institute on Aging (NIA: R56-AG066431) to G.S. and by the American Heart Association (AHA-20POST35211151 to J.G.).

Chronic kidney disease (CKD) is a heterogeneous group of disorders 2  |  U PDATE D C K D E PI D E M I O LO G Y

that manifest in various ways depending upon the severity of dis-
ease and the underlying cause(s).1
1  |  C K D : D E FI N ITI O N
Chronic kidney disease is defined by the presence of kidney damage or de-
2
creased kidney function for at least three months, irrespective of the cause.
Kidney damage generally refers to pathologic anomalies in the native or
transplanted kidney, established via imaging, biopsy, or deduced from clini-
cal markers like increased albuminuria—that is, albumin-to-creatinine ratio
(ACR) >30 mg/g (3.4 mg/mMol)—or urinary sediment alterations; decreased
kidney function refers to a reduced glomerular filtration rate (GFR), which is
3
usually estimated (eGFR) from the serum concentration of creatinine.
According to the US Centers for Disease Control and Prevention
(CDC), ~37 million people in the United States—~15% of adults—are
estimated to have CKD. Of note, 90% of adults with CKD do not
know they have it and 1 in 2 people with very low kidney function
who are not on dialysis are not aware of the fact that they have
CKD.4 Diabetes and hypertension are the major causes of CKD in
adults: According to the CDC, 1 in 3 adults with diabetes and 1 in 5
adults with hypertension may have CKD. According to the current
CDC statistics, CKD is more common in people aged 65 years or
older (38%) than in people aged 45-64 years (13%) or 18-44 years
(7%), and is slightly more common in women (15%) than men (12%);
moreover, African Americans are about 3 times more likely than
whites to develop ESKD.5

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2021 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.

J Clin Hypertens. 2021;23:831–834.  |

wileyonlinelibrary.com/journal/jch     831
 |
832      COMMENTARY
3  |  M EC H A N I S M S LE A D I N G TO C K D
In the Western world, the main risk factor for CKD develop-
ment is diabetes, which is present in 30%–50% of CKD patients.6
Hypertension and smoking are other strong factors increasing the
6
risk of CKD as well as the speed of its progression. Instead, in India,
Asia, and Sub-Saharan Africa, the leading cause of CKD is glomerulo-
nephritis, followed by CKD of unknown genesis, probably prompted
by soil pollution with heavy metals and pesticides and excessive use
of herbal-based traditional medicines.7 HIV contributes significantly
to CKD due to the direct glomerular interstitial damage caused by
HIV per se and to the significant nephrotoxicity of antiretroviral
therapies.6
Despite the diverse etiologies, the main mechanism of CKD is
believed to heavily rely on microvasculature dysfunction. Indeed,
hypertension, dyslipidemia, and smoking act on the endothelium in
glomeruli and interstitium, eventually resulting in the infiltration of
6
macrophages and other inflammatory cells. Macrophages activate
mesangial cells in glomeruli, facilitating their expansion and extra-
cellular matrix production, which results in substitution of capillar-
ies with matrix, thus reducing the surface through which the blood
filtration occurs resulting in a net filtration decrease and accumu-
8
lation of uremic toxins. At the same time, glomerulosclerosis is ac-
companied by dysfunction of podocytes, cells playing a central role
in the proper function of the glomerular filtration barrier. As a re-
sult, proteinuria develops and tubular epithelium becomes exposed
to proteins such as albumin, compliment system components, and
cytokines which further exacerbate the inflammatory response.8
Accumulation of damaged DNA in tubular epithelium through the
chronic inflammation produces cell cycle arrest, accompanied by a
switch to a specific type of secretory phenotype, which further fa-
cilitates pro-fibrotic modifications.8 Uncontrolled accumulation of
extracellular matrix decreases the capillary density, thus obstructing
oxygen and nutrient supply to tubular cells. Eventually, the kidney
tissue ends up with tubular atrophy and ubiquitous fibrosis.
4  |  C K D A N D C A R D I OVA S CU L A R D I S E A S E
The classification and staging of CKD are based on the cause(s), on
the level of albuminuria, and on glomerular filtration rate (GFR). 2
Kidney failure represents the end stage of CKD (ESKD: end-stage
kidney disease) and is defined as severely reduced kidney function or
treatment with dialysis. CKD has been shown to lead to an increased
risk for cardiovascular diseases, and cardiovascular complications
remain the most common cause of death and disability in CKD pa-
tients.9 Even with a normal eGFR, patients with ACR > 30 mg/g have
a significantly increased risk for all-cause and cardiovascular mortal-
ity, compared to subjects with a lower ACR.10
Vascular alterations reflect kidney dysfunction in CKD subjects,
and arterial stiffness is considered one of its most common mark-
ers.11 Arterial stiffness, characterized by a gradual degradation of
the elastic lamellae within the vascular media alongside structural
changes in collagen cross-linking and calcification, is present in
several cardiovascular and renal diseases, resulting in the reduced
ability of arteries to respond to changes in blood pressure. In the
current issue of the Journal, Guo and colleagues examined different
parameters of arterial stiffness in CKD patients, proposing the 24-
hour mean pulse pressure (PP) as the best marker to predict renal
outcomes.12
5  |  M EC H A N I S M S U N D E R LY I N G A RTE R I A L
S TI FFN E S S
Overall, arterial stiffness is a sign of structural and functional modi-
fications of the vascular wall that eventually lead to organ damage.
There are 2 main hemodynamic parameters of pressure and flow: a
steady component and a pulsatile component. The first one is rep-
resented by mean arterial pressure (MAP), the product of cardiac
output by vascular resistance, which is generally measured in hy-
pertensive subjects. The second one is represented by the PP, which
is mainly determined by stroke volume, aortic stiffness, and wave
reflections. As confirmed by Guo and collaborators, PP is a useful
parameter to evaluate arterial stiffness.12 PP is divided into brachial
PP and central PP; the difference between these two components is
defined PP amplification and it is approximately 14 mmHg. PP ampli-
fication might be superior than PP to detect arterial stiffness in CKD
patients, particularly in elderly populations.13
In patients with ESKD undergoing hemodialysis, clinical stud-
ies have shown that BP is frequently associated with an increase
in systolic BP (SBP) alone, with normal or even low diastolic BP
(DBP). These aspects could impact arterial stiffness because they
are associated with increased stiffness of large conduit arteries and
early wave reflections; importantly, an increased stiffness has been
shown to be independent of MAP.14
In this context, pulse wave velocity (PWV) remains a widely used
marker to evaluate arterial stiffness. PWV represents the pressure
generated by the ventricular contraction along the aorta.13,15 Since
pulse waves travel faster in stiffer arteries, arterial stiffness aug-
ments PWV, with normal values ranging between 3 and 5 m/s in
young people but commonly increase with age.
Chronic kidney disease and creatinine levels are among the most
critical determinants of PWV increase; in this scenario, a significant
relationship has been observed between GFR reduction, protein-
uria, and an increase in carotid-femoral PWV.16 Analyzing aortic
PWV in 101 living kidney donors and their 101 corresponding re-
cipients, Bahous and collaborators found that the major parameters
associated with PWV were time since nephrectomy (donation date)
in donors and renal rejection in recipients; additionally, plasma cre-
atinine doubling secondary to chronic allograft nephropathy was
significantly associated both to renal rejection and to donor PWV,
independent of age.17
Several studies have demonstrated that an optimal control of
blood pressure can prevent arterial stiffness.18-20 Furthermore, in
2005 Wang and coworkers demonstrated that a stepwise increase
COMMENTARY
in arterial stiffness reflects the stage of CKD21; in this study, a
greater PWV was observed in patients with more advanced CKD
from stages 1 to 5; SBP and the estimated GFR per 1.73 m2 were
the major clinical determinants of arterial stiffness in patients with
CKD independent of conventional risk factors for cardiovascular
21
diseases.
6  |   H OW TO Q UA NTI F Y A RTE R I A L
S TI FFN E S S ?
Arterial stiffness is commonly measured by PWV, which, as men-
tioned above, refers to the speed of a pressure wave's propagation
across an arterial tree. With age, arterial walls become less distensi-
ble, leading to increased PWV. Carotid-femoral pulse wave velocity
(cfPWV) is a well-validated measure of aortic stiffness that predicts
the likelihood of future cardiovascular events. Indeed, cfPWV can
predict future cardiovascular disease independently from conven-
tional atherosclerotic risk factors (sex, age, smoking status, systolic
blood pressure, dyslipidemia, and diabetes) in patients with ESKD. 22
The cfPWV threshold of 10m/s, established by the 2013 European
Society of Hypertension Guidelines, 23 is generally agreed upon as
an indication of asymptomatic hypertension-mediated organ dam-
age. cfPWV is measured by timing the movement of a pressure wave
between the carotid and femoral arteries. Compared to peripheral
measurements of PWV, cfPWV is more useful since central arter-
ies appear most susceptible to age-related stiffening. 24 Additionally,
brachial-ankle pulse wave velocity (baPWV) has been proposed as
an alternate measure of arterial stiffness as a wider screening tool
since it is easier and more convenient to conduct clinically. Other
parameters to measure arterial stiffness include the augmentation
index at heart rate 75 bpm (AIx@75)25 and the ambulatory arterial
stiffness index. 26
Changes in arterial stiffness may be hastened in hypertensive pa-
tients whose treatments fail to reduce their PWV. Moreover, failure
to reduce PWV in hypertensive patients was a significant predictor
of cardiovascular death in ESKD despite reasonable blood pressure
control. 27
There is conflicting evidence that early atherosclerosis is linked
to increased arterial stiffness. However, large arterial calcification
present in advanced atherosclerosis is associated with increased
PWV in CKD and ESKD.28 This association may be more related to
the plaque's contents (i.e., degree of calcification) than its size. 29,30
There are several direct hemodynamic consequences of increased
PWV. For one, age-related widening of PP—the difference between
systolic and diastolic blood pressure—is partly determined by arterial
stiffening. Furthermore, arterial stiffening is linked to wave reflec-
tion arriving earlier at the aorta during systole due to increased PWV,
likely affecting central PP. This aspect is significant since higher cen-
tral PP results in increased left ventricular afterload, predisposition
for ventricular hypertrophy, and decreased coronary blood flow.
|
      833
C O N FL I C T O F I N T E R E S T
None.
ORCID
Gaetano Santulli  https://orcid.org/0000-0001-7231-375X
REFERENCES
1. Wanner C, Lopau K. What Is the Utility of KDIGO Criteria to
Identify High-Risk Populations? Am J Kidney Dis. 2021;77(1):7-8.
2. Levey AS, Eckardt K-U, Dorman NM, et al. Nomenclature for kid-
ney function and disease: report of a Kidney Disease: Improving
Global Outcomes (KDIGO) Consensus Conference. Kidney Int.
2020;97(6):1117-1129.
3. Navaneethan SD, Zoungas S, Caramori ML, et al. Diabetes man-
agement in chronic kidney disease: synopsis of the 2020 KDIGO
clinical practice guideline. Ann Intern Med. 2020, In press.
4. Schrauben SJ, Chen H-Y, Lin E, et al. Hospitalizations among adults
with chronic kidney disease in the United States: A cohort study.
PLoS Med. 2020;17(12):e1003470.
5. Vart P, Powe NR, McCulloch CE, et al. National trends in the
prevalence of chronic kidney disease among Racial/Ethnic and
Socioeconomic Status Groups, 1988–2016. JAMA Netw Open.
2020;3(7):e207932.
6. Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney dis-
ease. Lancet. 2017;389(10075):1238-1252.
7. Fitria L, Prihartono NA, Ramdhan DH, Wahyono TYM, Kongtip
P, Woskie S. Environmental and occupational risk factors asso-
ciated with chronic kidney disease of unknown etiology in west
javanese rice farmers, Indonesia. Int J Environ Res Public Health.
2020;17(12):4521.
8. Humphreys BD. Mechanisms of renal fibrosis. Annu Rev Physiol.
2018;80:309-326.
9. Drueke TB, Floege J. Cardiovascular complications of chronic kid-
ney disease: pioneering studies. Kidney Int. 2020;98(3):522-526.
10. van der Velde M, Matsushita K, Coresh J, et al. Lower estimated glo-
merular filtration rate and higher albuminuria are associated with all-
cause and cardiovascular mortality. A collaborative meta-analysis
of high-risk population cohorts. Kidney Int. 2011;79(12):1341-1352.
11. Hoshide S, Suzuki D, Kario K. Circadian variation and arterial stiff-
ness in chronic kidney disease and their treatment. Am J Hypertens.
2020, In press.
12. Guo X, Li Y, Yang Y, et al. Noninvasive markers of arterial stiffness
and renal outcomes in patients with chronic kidney disease. J Clin
Hypertens (Greenwich). 2020. In press.
13. Avolio AP, Van Bortel LM, Boutouyrie P, et al. Role of pulse pressure
amplification in arterial hypertension: experts' opinion and review
of the data. Hypertension. 2009;54(2):375-383.
14. Salvi P, Parati G. Chronic kidney disease: Arterial stiffness and renal
function–a complex relationship. Nat Rev Nephrol. 2015;11(1):11-13.
15. Lanni F, Santulli G, Izzo R, et al. The Pl(A1/A2) polymorphism of
glycoprotein IIIa and cerebrovascular events in hypertension: in-
creased risk of ischemic stroke in high-risk patients. J Hypertens.
2007;25(3):551-556.
16. Gosse P, Safar ME. Arterial stiffness and plasma creatinine in
untreated hypertensive patients. Am J Hypertens. 2005;18(9 Pt
1):1140-1145.
17. Bahous SA, Stephan A, Blacher J, Safar ME. Aortic stiffness, living do-
nors, and renal transplantation. Hypertension. 2006;47(2):216-221.
18. Liew Y, Rafey MA, Allam S, Arrigain S, Butler R, Schreiber M. Blood
pressure goals and arterial stiffness in chronic kidney disease. J Clin
Hypertens (Greenwich). 2009;11(4):201-206.
 |
834      COMMENTARY
19. Balta S, Kucuk U, Demirkol S, Demir M, Ozturk C. Arterial stiffness
parameters in patients with chronic kidney disease. J Clin Hypertens
(Greenwich). 2014;16(2):157.
20. Lilitkarntakul P, Dhaun N, Melville V, et al. Blood pressure and not
uraemia is the major determinant of arterial stiffness and endothe-
lial dysfunction in patients with chronic kidney disease and minimal
co-morbidity. Atherosclerosis. 2011;216(1):217-225.
21. Wang MC, Tsai WC, Chen JY, Huang JJ. Stepwise increase in arte-
rial stiffness corresponding with the stages of chronic kidney dis-
ease. Am J Kidney Dis. 2005;45(3):494-501.
22. Ben-Shlomo Y, Spears M, Boustred C, et al. Aortic pulse wave
velocity improves cardiovascular event prediction: an individual
participant meta-analysis of prospective observational data from
17,635 subjects. J Am Coll Cardiol. 2014;63(7):636-646.
23. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines
for the management of arterial hypertension: the Task Force for
the Management of Arterial Hypertension of the European Society
of Hypertension (ESH) and of the European Society of Cardiology
(ESC). Eur Heart J. 2013;34(28):2159-2219.
24. Mitchell GF, Parise H, Benjamin EJ, et al. Changes in arterial stiffness
and wave reflection with advancing age in healthy men and women:
the Framingham Heart Study. Hypertension. 2004;43(6):1239-1245.
25. Nelson MR, Stepanek J, Cevette M, Covalciuc M, Hurst RT, Tajik
AJ. Noninvasive measurement of central vascular pressures with
arterial tonometry: clinical revival of the pulse pressure waveform?
Mayo Clin Proc. 2010;85(5):460-472.
26. Dolan E, Thijs L, Li Y, et al. Ambulatory arterial stiffness index as a
predictor of cardiovascular mortality in the Dublin Outcome Study.
Hypertension. 2006;47(3):365-370.
27. Townsend RR, Anderson AH, Chirinos JA, et al. Association of pulse
wave velocity with chronic kidney disease progression and mor-
tality: findings from the CRIC study (Chronic Renal Insufficiency
Cohort). Hypertension. 2018;71(6):1101-1107.
28. Haydar AA, Covic A, Colhoun H, Rubens M, Goldsmith DJ. Coronary
artery calcification and aortic pulse wave velocity in chronic kidney
disease patients. Kidney Int. 2004;65(5):1790-1794.
29. Gambardella J, Wang X, Mone P, Khondkar W, Santulli G. Genetics
of adrenergic signaling drives coronary artery calcification.
Atherosclerosis. 2020;310:88-90.
3 0. Cecelja M, Hussain T, Greil G, et al. Multimodality imaging of sub-
clinical aortic atherosclerosis: relation of aortic stiffness to calcifica-
tion and plaque in female twins. Hypertension. 2013;61(3):609-614.
How to cite this article: Wilson S, Mone P, Jankauskas SS,
Gambardella J, Santulli G. Chronic kidney disease: Definition,
updated epidemiology, staging, and mechanisms of increased
cardiovascular risk. J Clin Hypertens. 2021;23:831–834. https://
doi.org/10.1111/jch.14186